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!rofessionaI "esponsibiIity #oncern
"$!%"& (%")
Local File #: Local #:
Employer:
Worksite (ward/unit/offce):
When did the incident or issue occur?
Date yyyy/mm/dd Time Shift
Detailed Description of ncident/ssue (Do not use names of patients, residents, clients, staff, doctors, or others):
Was this concern reported to anyone? Yes No Why or Why not?
Recommendations (What is needed to prevent this incident or issue from occurring again?):
!"#
Purpose
Nurses are required by the standards of their professional
licensing bodies to advocate for practice environments
that have the organizational and human support systems,
and the resources necessary for safe, competent, and
ethical nursing care.
Employers and the United Nurses of Alberta have
agreed that it is of mutual beneft to fnd resolutions to
issues of concern including the safety and quality of
patient/resident/client/care. Completing a Professional
Responsibility Concern Report Form is a specifc and
safe mechanism for nurses to advocate for the safety of
patients/residents/clients.
nstructions
1. Complete this form as soon as possible after observ-
ing conditions in which you believe the safety of
patients/clients/residents may be at risk, or in situa-
tions where you believe administrative action needs to
be taken to prevent risks to patients/residents/clients.
2. Do not use the names of patients, residents, clients,
staff, doctors or others in completing this form.
3. This form does not replace the employer's incident
report form or other reporting. Refer to the employ-
ers' policies to determine whether an incident report
is required in this situation.
4. You do not have to obtain permission from a manager
to complete this report of a Professional Responsi-
bility Concern. However, it may be appropriate and
advisable to inform a management representative
of the conditions you are documenting in this form.
5. This form and the information contained in it is the
property of the United Nurses of Alberta. The con-
cerns documented in this form will be presented to the
Professional Responsibility Committee or alternate in
your worksite for resolution as provided in the Col-
lective Agreement between UNA and the Employer.
6. Deliver or send the white copy of the PRC Report
Form to the Local offce of the United Nurses of
Alberta in your worksite
7. Keep a copy for your personal records.
United Nurse of AIberta ProvinciaI Ofce
700-11150 Jasper Avenue NW
Edmonton AB T5K 0C7
(780) 425-1025/1-800-252-9394
(780) 426-2093 (fax)
www.una.ab.ca nurses@una.ab.ca
Name (Printed) E-Mail
Signature Date Report Filed yyyy/mm/dd Phone